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Indian Pediatr 2012;49: 51-53
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Cutaneous Manifestations of Chikungunya Fever |
KA Seetharam, K Sridevi and P Vidyasagar
From the Department of Dermatology and STD, Katuri
Medical College, Guntur, AP, India.
Correspondence to: Dr KA Seetharam, 3-28-18/155,
Rajendranagar 4th line, Guntur, Andhra Pradesh, India.
Email: [email protected]
Received: January 10, 2011;
Initial review: January 31, 2011;
Accepted: April 19, 2011.
Published online: 2011, August 15.
PII: S097475591100033-2
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Abstract
Chikungunya fever, a re-emerging RNA viral infection
produces different cutaneous manifestations in children compared to
adults. 52 children with chikungunya fever, confirmed by positive IgM
antibody test were seen during 2009-2010. Pigmentary lesions were common
(27/52) followed by vesiculobullous lesions (16/52) and maculopapular
lesions (14/52). Vesiculobullous lesions were most common in infants,
although rarely reported in adults. Psoriasis was exacerbated in 4
children resulting in more severe forms. In 2 children, guttate
psoriasis was observed for the first time.
Key words: Chikungunya, Cutaneous Manifestations, India, Skin,
Viral infection.
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Chikungunya fever is a re-emerging viral infection
characterized by abrupt onset of fever, severe arthralgia, constitutional
symptoms and rash lasting for 1-7 days [1-4]. Cutaneous manifestations in
children differ from adults. We report various cutaneous lesions observed
in children in the recent epidemic in Andhra Pradesh.
Methods
Children affected with chikungunya infection attending
our out-patient department during the recent epidemic of 2009 and 2010
were observed for cutaneous manifestations. Diagnosis was based on the
criteria suggested by the National Institute of Communicable Diseases [5].
The disease was confirmed by positive IgM antibody against the virus. Skin
biopsy was done in selected lesions.
Results
Fifty two children (28 females) with confirmed
chikungunya infection were seen. Twenty two were infants, the youngest
being 22 days. Cutaneous lesions observed are listed in Table I.
Pigmentary lesions were generalized, brownish black and predominantly
involved face and extremities (Fig.1a and 1b).
Nine children showed discrete scattered pigmented macules without any
background or surrounding erythema (Fig. 1c).
Vesiculobullous lesions were seen mostly in infants. They were
symmetrical, flaccid, and containing clear serous fluid without any
perilesional erythema (Fig. 2). Histopathology of bullous
lesions showed intra epidermal cleavage and periappendageal infiltrate
containing lymphocytes and neutrophils. Generalized maculopapular eruption
or erythema with islands of normal skin were noted, mostly 2-3 days after
onset of fever. It started on trunk and then spread centrifugally
involving face, palms and soles. Mucosal regions were spared. Mostly it
subsided in 4-5 days, but in 5 cases there was peeling of the skin over
body, palms and soles, resembling staphylococcal scalded skin syndrome (SSSS).
However, these children were not irritable and not toxic and there was no
tenderness in the lesions. Mild edema of hands and feet were observed in 6
children. Existing psoriasis exacerbated in 4 children and 2 children
developed guttate psoriasis. Systemic features observed were fever,
arthralgia, loose stools, and seizures (3/52); and one child developed
meningoencephalitis but recovered uneventfully. Lymphopenia was observed
in 5 children.
TABLE I Cutaneous Manifestations of Chikungunya (N=52)
Pigmentation |
27 (51.9%) |
Diffuse |
18 (34.6%) |
Macular |
9 (17.3%) |
Maculopapular |
14 (26.9%) |
Morbilliform |
8 (15.4%) |
Generalized erythema with islands of
normal skin |
6 (11.5%) |
Vesiculobullous |
16 (30.7%) |
Petechiae |
4 (7.6%) |
Acrocyanosis |
3 (5.7%) |
Exacerbation of existing diseases |
6 (11.5%) |
Psoriasis |
4 (7.6%) |
Lichen planus |
2 (3.8%) |
Guttate psoriasis |
2 (3.8%) |
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Fig.1 (a) Hyperpigmentation on face, (b)
Hyperpigmentation on extremities and (c) Macular
pigmentation on trunk. |
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Fig.2 Multiple flaccid bullae on both legs. |
Discussion
We observed that cutaneous manifestations of
chikungunya are different compared to adults. Generalized pigmentary
changes were the commonest in our series whereas it was localized in
adults in the form of centrofacial or melasma like pigmentation. The exact
mechanism of pigmentation is not known. Inamdar, et al. [6]
proposed virus triggered increased intraepidermal dispersion/retention of
melanin. Maculopapular eruption was another common feature and did not
differ significantly from adults except that in children it developed
early, 1-2 days after fever compared to 4-6 days in adults. It may be in
the form of erythematous macules, morbiliform rash or generalized erythema
with islands of normal skin. Dengue also can produce similar clinical
picture but associated features differentiate the two. Dengue may coexist
with chikungunya infection and a serological exclusion is always desirable
[7]. Hemorrhagic manifestations are rare in chikungunya infection.
Ecchymoses and subungual hemorrhages are reported [1], and
thrombocytopenia is occasional and not significant. Four of our patients
showed few petechiae and none showed significant thrombocytopenia.
Conditions like rubella, measles, infectious mononucleosis, scarlet fever,
Kawasaki disease, acute retroviral syndrome, leptospirosis, rheumatic
fever, and drug reactions have to be differentiated by appropriate
clinical and laboratory features [8].
Vesiculobullous lesions were most commonly seen in
infants and rarely reported in adults. These were commonly seen on
extremities with more frequent involvement of lower extremities, including
buttocks and thighs [9,10]. They developed 2-3 days after fever and
subsided in 6-10 days. Valamparampil, et al. [9] reported
symmetrical superficial vesiculobullous lesions and acrocyanosis without
any hemodynamic alterations. Riyaz, et al. [3] reported charring,
vesicles and bullae, followed by peeling, clinically mimicking toxic
epidermal necrolysis but without mucosal involvement. Absence of
perilesional erythema and crusting, Gram stain and cultures from the
bullae exclude impetigo. Biopsy from the bullae showed intraepidermal
cleavage in our cases and by Robin, et al. [10], but Riyaz, et
al. [3] reported both intraepidermal and sub-epidermal cleavage along
with periadnexal infiltrate. Vesicles and bullae were probably caused by
viral replication in the epidermis causing focal necrosis, ballooning
degeneration, or nuclear disruption followed by an immune response and
infiltration by leucocytes [3].
Exacerbation of existing skin diseases has previously
also been documented with chikungunya infection [3,6]. Aphthous like
ulcers, erythema multiforme like lesions, and lymphedema, which were seen
in adults with this infection were not seen in our patients.
The cutaneous lesions of chikungunya need reassurance
and symptomatic treatment. The maculo-papular eruption was treated with
antihistamines and topical soothing applications like calamine lotion.
Hyper-melanosis was managed with a short course of mild topical steroids
along with emollients. Vesiculobullous lesions were treated with local
cleaning and topical antibiotics.
Contributors: KAS conceived and designed the study.
He revised the manuscript for important intellectual content and will act
as guarantor of the study. KS and PV collected data conducted the
laboratory tests, interpreted them and drafted the paper. The final
revised manuscript was approved by all authors.
Funding: None; Competing interests:
None stated.
What This Study Adds?
• Vesiculobullous lesions were common cutaneous manifestation of
chikungunya fever in infants.
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